U.S. patent application number 16/797960 was filed with the patent office on 2020-09-03 for absorbable implants for plastic surgery.
The applicant listed for this patent is Tepha, Inc.. Invention is credited to Fabio Felix, Antonio Fosco, David P. Martin, Arikha Moses, Said Rizk, Bruce Van Natta, Simon F. Williams.
Application Number | 20200276006 16/797960 |
Document ID | / |
Family ID | 1000004838252 |
Filed Date | 2020-09-03 |
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United States Patent
Application |
20200276006 |
Kind Code |
A1 |
Felix; Fabio ; et
al. |
September 3, 2020 |
ABSORBABLE IMPLANTS FOR PLASTIC SURGERY
Abstract
Absorbable implants for breast surgery that conform to the
breast parenchyma and surrounding chest wall have been developed.
These implants support newly lifted breast parenchyma, and/or a
breast implant. The implants have mechanical properties sufficient
to support a reconstructed breast, and allow the in-growth of
tissue into the implant as it degrades. The implants have a
strength retention profile allowing the support of the breast to be
transitioned from the implant to regenerated host tissue, without
significant loss of support. Three-dimensional implants for use in
minimally invasive mastopexy/breast reconstruction procedures are
also described, that confer shape to a patient's breast. These
implants are self-reinforced, can be temporarily deformed,
implanted in a suitably dissected tissue plane, and resume their
preformed three-dimensional shape. The implants are preferably made
from poly-4-hydroxybutyrate (P4HB) and copolymers thereof. The
implants have suture pullout strengths that can resist the
mechanical loads exerted on the reconstructed breast.
Inventors: |
Felix; Fabio; (Lexington,
MA) ; Fosco; Antonio; (Lexington, MA) ;
Martin; David P.; (Lexington, MA) ; Moses;
Arikha; (Lexington, MA) ; Van Natta; Bruce;
(Lexington, MA) ; Rizk; Said; (Lexington, MA)
; Williams; Simon F.; (Lexington, MA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Tepha, Inc. |
Lexington |
MA |
US |
|
|
Family ID: |
1000004838252 |
Appl. No.: |
16/797960 |
Filed: |
February 21, 2020 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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16042879 |
Jul 23, 2018 |
10568728 |
|
|
16797960 |
|
|
|
|
15489291 |
Apr 17, 2017 |
10028818 |
|
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16042879 |
|
|
|
|
14813454 |
Jul 30, 2015 |
9636211 |
|
|
15489291 |
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|
14329760 |
Jul 11, 2014 |
9532867 |
|
|
14813454 |
|
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61845236 |
Jul 11, 2013 |
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61993511 |
May 15, 2014 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61L 2430/04 20130101;
A61F 2/0063 20130101; D04H 1/728 20130101; A61F 2/12 20130101; A61F
2220/0008 20130101; A61L 27/58 20130101; B29C 48/05 20190201; A61F
2/52 20130101; A61L 31/148 20130101; A61F 2210/0061 20130101; B29C
48/25 20190201; D04H 13/001 20130101; A61F 2210/0004 20130101; A61F
2210/0066 20130101; A61L 27/56 20130101; B29L 2031/7532 20130101;
A61L 27/50 20130101; A61F 2002/523 20130101 |
International
Class: |
A61F 2/00 20060101
A61F002/00; B29C 48/05 20060101 B29C048/05; B29C 48/25 20060101
B29C048/25; A61L 27/50 20060101 A61L027/50; A61L 27/56 20060101
A61L027/56; A61L 27/58 20060101 A61L027/58; D04H 1/728 20060101
D04H001/728; A61F 2/12 20060101 A61F002/12; D04H 13/00 20060101
D04H013/00; A61F 2/52 20060101 A61F002/52; A61L 31/14 20060101
A61L031/14 |
Claims
1-15. (canceled)
16. An absorbable implant for breast reconstruction comprising a
porous biodegradable polymeric scaffold formed into a
three-dimensional shape, wherein the scaffold is designed to confer
shape to the breast, and has a shape selected from one or more of
the group comprising: dome, hemisphere, hemi-ellipsoid.
17. The implant of claim 16, wherein the implant further comprises
one or more of the following: tab, retainer, barb and tack.
18. The implant of claim 16, wherein the scaffold has one or more
of the following dimensions: a width at its base of 8 to 20 cm; a
height or radius of curvature of 5 to 14 cm; a width that is 1 to 2
cm less than the width of the patient's breast.
19. The implant of claim 16, wherein the implant has shape
memory.
20. The implant of claim 19, wherein the implant assumes a
preformed shape following temporary deformation.
21. The implant of claim 16, wherein the scaffold has a suture
pullout strength greater than 10 N.
22. The implant of claim 16, wherein the implant can support a
pressure of at least 0.1 kPa, or can withstand a load of at least 5
N.
23. The implant of claim 16, wherein the scaffold has pore
diameters of at least 50 .mu.m or 100 .mu.m.
24. The implant of claim 16, wherein the implant has an outlying
border that is reinforced by a continuous or interrupted ring.
25. The implant of claim 16, wherein the porous scaffold is formed
with one or more of the following: mesh, monofilament mesh,
multifilament mesh, strips, fabric, woven, non-woven, melt-blown,
knitted or braided constructs, laminate, nanospun, electrospun, dry
spun, filament, thread, strand, string, fiber, yarn, wire, film,
tape, felt, multifilament, or monofilament.
26. The implant of claim 16, wherein the porous scaffold is formed
by 3D printing or salt leaching.
27. The implant of claim 16, wherein the implant further comprises
one or more of the following: cellular adhesion factor,
fibronectin, vitronectin, laminin, elastin, fibrinogen, collagen
types I, II and V, polymers or copolymers of ethylene oxide and
propylene oxide, surfactant, emulsifier, bioactive agent, agent to
improve cell attachment, tissue in-growth and tissue maturation,
growth factor, cellular differentiating factor, cellular recruiting
factor, cell receptor, cell-binding factor, cell signaling
molecule, cytokine, molecules to promote cell division, cell
proliferation and extracellular matrix deposition, fibroblast
growth factor, transforming growth factor, platelet derived growth
factor, epidermal growth factor, granulocyte-macrophage colony
stimulating factor, vascular endothelial growth factor,
insulin-like growth factor, hepatocyte growth factor, interleukin
1-B, interleukin-8, nerve growth factor, antimicrobial agent,
antibiotic, disinfectant, oncological agent, anti-scarring agent,
anti-inflammatory agent, anesthetic, small molecule drug,
anti-angiogenic factor, pro-angiogenic factor, immunomodulatory
agent, blood clotting agent, protein, collagen, antibody, peptide,
polysaccharide, chitosan, alginate, polysaccharide, hyaluronic acid
and derivative thereof, nucleic acid molecule, steroid,
hydroxyapatite, platelet rich plasma, bacitracin, biguanide,
trichlosan, gentamicin, minocycline, rifampin, vancomycin,
cephalosporin, copper, zinc, silver, gold, DNA, RNA, siRNA, mRNA,
contrast agent, radiopaque marker, allograft material, xenograft
material, and system for controlled release of therapeutic or
prophylactic agent.
28. The implant of claim 16, wherein the implant comprises one or
more of the following: polymers of glycolic acid, lactic acid,
1,4-dioxanone, trimethylene carbonate, 3-hydroxybutyric acid,
.epsilon.-caprolactone, including polyglycolic acid, polylactic
acid, polydioxanone, polycaprolactone, copolymers of glycolic and
lactic acids, VICRYL.RTM., MAXON.RTM. and MONOCRYL.RTM. polymers,
poly(lactide-co-caprolactone); poly(orthoester); polyanhydride;
poly(phosphazene); polyhydroxyalkanoate; synthetically or
biologically prepared polyester; polycarbonate; tyrosine
polycarbonate; polyamide, synthetic and natural polyamide,
polypeptide, poly(amino acid); polyesteramide; poly(alkylene
alkylate); polyether; polyethylene glycol; polyethylene oxide;
polyvinyl pyrrolidone; polyurethane; polyetherester; polyacetal;
polycyanoacrylate; poly(oxyethylene)/poly(oxypropylene) copolymer;
polyacetal, polyketal; polyphosphate; phosphorous-containing
polymer; polyphosphoester; polyalkylene oxalate; polyalkylene
succinate; poly(maleic acid); silk, recombinant silk, silk
derivative; chitin; chitosan; modified chitosan; biocompatible
polysaccharide; hydrophilic or water soluble polymer; polyvinyl
pyrrolidone (PVP), PVP with blocks of other biocompatible or
biodegradable polymer, including poly(lactide),
poly(lactide-co-glycolide), or polycaprolactone and copolymers
thereof, including random copolymers and block copolymers
thereof.
29. The implant of claim 16, wherein the implant comprises
poly-4-hydroxybutyrate (P4HB) or a copolymer thereof.
30. The implant of claim 29, wherein the P4HB or copolymer thereof
has a weight average molecular weight within the range of 50 kDa to
1,200 kDa, by gel permeation chromatography (GPC) relative to
polystyrene.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application is a continuation of pending U.S. Ser. No.
15/489,291, filed Apr. 17, 2017, which is a continuation of U.S.
Ser. No. 14/813,454, filed Jul. 30, 2015, now U.S. Pat. No.
9,636,211, which is a continuation U.S. Ser. No. 14/329,760, filed
Jul. 11, 2014, now U.S. Pat. No. 9,532,867, which claims the
benefit of and priority to U.S. Ser. No. 61/993,511 filed May 15,
2014 and U.S. Ser. No. 61/845,236, filed Jul. 11, 2013, all of
which are incorporated by reference in their entirety.
FIELD OF THE INVENTION
[0002] The present invention generally relates to absorbable
implants that are shaped or have shaped memory so they can conform
to anatomical structures or confer shape to anatomical structures,
and are designed for use in plastic surgery procedures.
BACKGROUND OF THE INVENTION
[0003] Numerous plastic surgery procedures are performed each year
to restore or correct the form or function of the body. Many of
these procedures seek to restore a youthful appearance, or even to
enhance one's existing appearance. Natural factors, such as aging
and gravity, contribute to the loss of the youthful appearance. For
example, skin laxity, loss of muscle tone, and attenuation of
ligaments can result in ptosis (drooping) of the breast. Plastic
surgeons have developed a plethora of surgical techniques to
correct the ptosis of different anatomical structures that occurs
with aging. These techniques vary in the type of incision,
direction of incision, plane of dissection, amount of dissection,
extent of repositioning of tissue, the use of different types of
sutures, different suturing techniques, and different fixation
techniques. Almost all of them rely on the use of the pre-existing
skin envelope as the support system for the newly lifted tissue.
These approaches almost invariably result in recurrent ptosis,
since the surgeon is merely relying on the aging and sagging
surrounding tissues that have already failed to provide the
necessary support to maintain a normal appearance. For example,
de-epithelialization, flap transposition, gland repositioning or
suturing will not alter the physical properties of the patient's
tissue. At most, these techniques only slow recurrent ptosis by
creating internal scars that provide limited reinforcement. And
even the scarring process varies from patient to patient making
this limited approach highly unpredictable. Notably, there is no
attempt with these approaches to change the physical properties of
the local tissue in order to improve the outcome.
[0004] Several surgeons have attempted to reinforce their lift
procedures using surgical meshes in mastopexy and breast
reconstruction procedures. Some of these techniques have also
incorporated the use of various reinforcing materials similar to
those used in hernia repair, such as flat polymeric meshes,
allografts, xenografts and autografts.
[0005] In 1981, Johnson described the use of MARLEX.RTM.
(cryastalline polypropylene) mesh to convert the support of breast
tissue after mastopexy from a cutaneous origin to a skeletal origin
by attaching the mesh to the area of the second rib, (Johnson,
Aesth. Plast. Surg. 5:77-84 (1981)). The flat MARLEX.RTM. mesh is a
permanent mesh made from polypropylene, and was implanted to
provide two slings in each breast that supported the breast tissue.
It is not replaced with regenerated host tissue.
[0006] Auclair and Mitz have described a mesh assisted mastopexy
using a flat absorbable mesh and a periareolar skin resection
technique (Auclair and Mitz, Ann. Chir. Plast. Esthet. 38:107-113
(1993)). A rapidly absorbing VICRYL.RTM. mesh was placed around the
anterior surface of the breast gland in order to form an internal
bra.
[0007] Goes has reported the use of polyglactin 910 (an absorbable
copolymer of 90% glycolide and 10% L-lactide, also known as
VICRYL.RTM.) and a mixed mesh (containing 60% polyglactine 910 and
40% permanent polyester) in a periareolar mammoplasty using a
double skin technique (Goes, Plast. Reconstr. Surg. 97:959-968
(1996)). The technique involves dissecting the soft tissue envelope
away from the parenchyma, and wrapping the breast parenchyma with a
mesh to help provoke the formation of a vigorous connective scar to
produce a breast lining structure that would be less susceptible to
ptosis. The soft tissue envelope is then closed around the
parenchyma. In the procedure, a dermal flap was created around the
nipple-areolar complex, and after the lift procedure was completed,
the dermal flap was sutured on top of the breast gland to provide
an internal cutaneous lining. The mesh was then sutured on top of
the dermal flap so that it surrounded the breast gland, and the
ends of the mesh were sutured together in the central part of the
superior aspect of the breast to form a conical breast shape with
slight elevation of the breast. Although the mesh was found to
provide short-term support, it was absorbed after 3 months. Better
results were reported with the mixed (partially absorbable) mesh.
The latter provided a less elastic envelope, avoided tissue
displacement, and improved the quality and duration of the new
breast shape (Sampaio Goes, Clin. Plast. Surg. 29:349-64
(2002)).
[0008] U.S. Pat. No. 6,210,439 to Firmin et al. discloses a
circular VICRYL.RTM. mesh with a V-shaped opening extending from
its center that has a metallic reinforcing wire running around the
periphery. The implant assumes a conical shape suitable for
mammoplasty when the reinforcing wire is tightened. However,
VICRYL.RTM.mesh degrades rapidly in vivo with 50% loss of strength
retention at five days, no residual strength at 10-14 days, and
complete absorption at 42 days. This strength retention profile
provides very little time for the formation of regenerated host
tissue that can withstand the forces exerted on the breast. In
fact, Goes and Bates concluded "absorbable synthetic meshes do not
persist sufficiently to have an impact on the recurrence of breast
ptosis" [see Goes and Bates, Periareolar mastopexy with FortaPerm,
Aesth. Plast. Surg. 34:350-358 (2010)].
[0009] WO 2009/001293 by de Bruijn et al. also discloses permanent
mesh implants for use in mesh assisted mastopexy (see also de
Bruijn et al., Aesth. Plast. Surg. 32:757-765 (2008)). These
implants were performed in the shape of oblique circular cones with
the apex removed so that they could be placed all the way around
the entire breast gland with the nipple-areolar complex remaining
exposed (effectively making an internal bra). The cones were made
from two different non-degradable materials, polypropylene and a
permanent polyester material. The results obtained with the softer
polyester cone implants were considered to be superior to those
achieved with the more rigid polypropylene implants. In the latter
case, rippling of the polypropylene mesh in some patients resulted
in a less than satisfactory appearance, the margins of the mesh
were often palpable, and in some cases extrusion of the mesh
occurred. Examination of the polyester mesh removed from a patient
in pain was reported to show that the mesh appeared to possess the
proper mechanical characteristics necessary to reinforce a ptotic
breast during mastopexy (de Bruijn et al., Plast. Reconstr. Surg.
124:364-71 (2009)).
[0010] Van Deventer et al. has also reported the use of an internal
breast support system for mastopexy using a partially degradable
mesh that was formed into a cone by overlapping the ends of the
mesh (van Deventer et al. Aesth. Plast. Surg. 36:578-89 (2012)).
The mesh contained 50% polypropylene and 50% absorbable
polyglactin.
[0011] A permanent implant for soft tissue support, made from
polytetrafluoroethylene (ePTFE), which can be used in forming a
predetermined breast shape is disclosed by WO 2004/096098 by
Hamilton et al. WO 2006/117622 by Lauryssen et al. also discloses a
permanent implant for soft tissue support of the breast that is
generally L-shaped or U-shaped, but is made from polypropylene.
[0012] U.S. Pat. No. 7,476,249 to Frank discloses an implantable
sling shaped prosthesis device for supporting and positioning a
breast implant in a patient, wherein the device is configured from
a sheet of a chemically inert permanent material, such as
polytetrafluoroethylene or silicone, to support the breast implant.
The sling shaped device provides support to the breast but does not
have shape memory that allows it to confer shape to the breast or
retain a three-dimensional shape.
[0013] U.S. Patent Application Publication No. 2009/0082864 by Chen
et al. also discloses a prosthetic device for supporting a breast
implant made from a mesh. The device has a flat back wall, a
concave front wall, and a curved transitional region between these
walls that forms a smoothly curved bottom periphery.
[0014] U.S. Pat. No. 7,670,372 to Shfaram et al. discloses a
minimally invasive breast lifting system. The system incorporates a
biological material, such as tendons, or synthetic material, such
as silicone or GOR-TEX.RTM. material (polytetrafluoroethylene), to
cradle the breast.
[0015] U.S. Patent Application Publication No. 2012/0283826 by
Moses et al. discloses mastopexy systems having an insertion
device, a suspension strut, and a lower pole support. The implanted
suspension strut provides pole projection and attachment points for
the lower pole support, and the lower pole support can lift the
lower pole of the breast.
[0016] U.S. Patent Application Publication No. 2008/0097601 by
Codori-Hurff et al. discloses mastopexy and breast reconstruction
procedures assisted by the use of processed tissue material derived
from intestine or dermis. The tissue material is cut to a crescent
shape, and may have up to 10 layers bonded together. The bonded
layers can be chemically cross-linked.
[0017] U.S. Patent Application Publication No. 2008/0027273 by
Gutterman discloses a minimally invasive mastopexy system having a
soft tissue support sling. The latter can be made from
polyethylene, PEBAX.RTM. (polyether block amide), PEEK (polyether
ether ketone), nylon, PET (polyethylene terephthalate), ePTFE
(polytetrafluoroethylene), silicone, or even a metal lattice. The
device is designed to provide support by suspending the breast from
the upper pole region using a bone anchor. The device does not have
shape memory, and does not use shape memory to confer shape to the
breast.
[0018] U.S. Patent Application Publication No. 2010/0331612 by
Lashinski et al. discloses a system for performing a minimally
invasive mastopexy (breast lift) that can include an elongate
flexible sling used as a soft tissue anchor. The sling can be made
from a mesh, and the mesh can be made, for example, from
polypropylene. The sling is designed to resist weakening or
degradation when implanted.
[0019] Notably, there is very little innovation in the design of
flat meshes that when implanted can provide a specific conformation
to the inferior support envelope without bunching or rippling. The
problems associated with permanent mesh could be overcome by using
an absorbable implant that is replaced with regenerated host tissue
capable of supporting the reconstructed breast. Ideally, the
absorbable implant would be pre-shaped to ensure a good outcome,
and for ease of use. Notably, there are no disclosures of the use
of any pre-shaped asymmetric absorbable implants for use in
mastopexy or breast reconstruction. Prior disclosures have only
described symmetrical two-dimensional shapes, such as ellipse
shaped implants, which wrinkle, bunch or fold when the implant is
attached to the breast mound and the fascia (see, for example, U.S.
Patent Application Publication No. 2008/0097601 by Codori-Hurff et
al.), pre-shaped hammocks and slings which are symmetrical
three-dimensional shapes that are designed to conform to the lower
pole of the breast (see, for example, U.S. Pat. No. 7,476,249 to
Frank which discloses an implantable sling), or pre-shaped
symmetrical cone shaped implants [de Bruijn et al., Aesth. Plast.
Surg. 32:757-765 (2008)]. In order to make implants that conform to
the anatomy of the breast and anchor to the chest wall, the plastic
surgeon needs to trim, cut, or excise material from the
implant.
[0020] PCT/US2012/027975 by Galatea Corporation discloses mastopexy
systems to provide superior pole projection, to prevent ptosis
recurrence, which may include tabs to enhance positioning.
[0021] U.S. Patent Application Publication No. 20120185041 to
Mortarino et al. discloses methods for using silk meshes in breast
augmentation and breast reconstruction with a knit pattern that
substantially prevents unraveling when cut. Mortarino does not
disclose silk meshes with shape memory, asymmetric or
three-dimensional shapes. Mortarino also does not disclose meshes
with shape memory that confer shape to a breast.
[0022] It is therefore an object of the invention to provide
scaffold implants strong enough to support a lifted breast with or
without a breast implant wherein the scaffold allows a transition
from support by the implant to support by regenerated host tissue
without any significant loss of support for the breast.
[0023] It is another object of the invention to provide implants
that have suture pullout strengths strong enough to support the
weight of a breast and/or a breast augmented with a breast
implant.
[0024] It is still another object of the invention to provide
implants that have a shape and design that upon placement,
substantially conforms to the breast and chest wall without
buckling or bunching, and sculpts the breast into the desired
shape.
[0025] It is yet another object of the invention to provide shape
memory implants for use in mastopexy and breast reconstruction
procedures that can be temporarily deformed, and have the ability
to spring open into a three-dimensional shape after delivery into a
suitably shaped tissue plane of the body.
[0026] It is still further an object of the invention to provide
shape memory implants for use in mastopexy and breast
reconstruction procedures that confer shape on the breast, and can
take the shape of the lower pole of the breast, and implants that
are self-reinforced so they possess shape memory and can open into
three-dimensional shapes.
SUMMARY OF THE INVENTION
[0027] Absorbable implants for use in breast surgery that are
designed to conform to the breast parenchyma and surrounding chest
wall have been developed. These implants are designed to support
newly lifted breast parenchyma, and/or a silicone breast implant.
The implants have initial mechanical properties sufficient to
support a breast, with or without a breast implant, and allow the
in-growth of tissue into the implant as the implant degrades. The
implants also have a strength retention profile that allows the
support of the breast to be transitioned from the implant to
regenerated host tissue without any significant loss of support for
the reconstructed breast. The implants can be made from
poly-4-hydroxybutyrate (P4HB) and copolymers thereof. The implants
have suture pullout strengths that can resist the mechanical loads
exerted on the breast.
[0028] In one embodiment, the implants have a shape that: is
conformable to the breast and chest wall without causing buckling
or bunching; minimizing the need to trim the implant during
surgery; and sculpturing the breast into the desired shape.
[0029] Absorbable implants are also disclosed with shape memory.
These shape memory implants can be temporarily deformed, and can be
delivered by minimally invasive techniques for mastopexy and breast
reconstruction procedures. The implants can resume their preformed
shapes after delivery into a suitably shaped tissue plane in the
body. The shaped memory implants can confer a shape to the breast.
In a preferred embodiment, the absorbable implants have an
asymmetric shape.
BRIEF DESCRIPTION OF THE DRAWINGS
[0030] FIG. 1 is a diagram of an asymmetric implant for breast
reconstruction with a teardrop shape and additional tabs (12, 14,
16, 18).
[0031] FIG. 2 shows a diagram of an asymmetric two-dimensional
implant (95) for use in reconstruction of the right breast with a
width (W), height (H), a mid-body curved support (90), and tabs
(94) to allow the implant to stretch over the breast mound without
bunching.
[0032] FIG. 3 is a diagram of a split metal form (20), including an
inwardly curving half (22) and a mating outwardly curving half (28)
with a semicircular groove (26) in the outlying border of the
inwardly curving half (28), which is used to make implants that can
assume a three-dimensional shape unaided. A line in the outwardly
curving half (24) designated by the letters "AA" denotes the
position of a cross-section view (32) of the outwardly curving half
of the mold (24). A material (30) to be molded is sandwiched in the
split metal mold.
[0033] FIG. 4A is a diagram of a hemi-ellipsoid implant shape. FIG.
4B is a schematic of the implant with the cross-section dimensions
of its three-dimensional shape defined by tri-axial dimensions "a",
"b" and "c".
[0034] FIG. 5 is a diagram of an implant for breast reconstruction
with a wide upper span (40) to facilitate sling support and
encompass the breast mound, and an extra-large bottom tab (42) to
support the breast vertical pillar and shape the IMF. The
two-dimensional implant shape is designed to minimize bunching or
folding of the implant during breast reconstruction.
[0035] FIG. 6 is a diagram of a two-dimensional implant for breast
reconstruction designed to support the breast mound that features a
curved upper line (54) to improve breast mound conformity, a short
right to left span to anchor the scaffold to the breast mound, and
an oblong lower tab (50) with rounded corners to support the
vertical pillar or fold under the IMF to provide shape and support
to the breast.
[0036] FIG. 7 is a diagram of an implant for breast reconstruction
designed to support the breast mound and distribute the load to
specific anchoring positions. The two-dimensional implant features
a wide right to left curved span to provide sling support defined
by width "W", and insets (74) between anchor tabs (72 and 76) on
the lower side to conform to the shape of the IMF without bunching
of the implant.
[0037] FIG. 8 shows an example of a two-dimensional crescent shaped
implant with a width (W) and height (H).
[0038] FIG. 9 shows a diagram of a two-dimensional implant for
breast reconstruction of width (W) and height (H.sup.1) with a
recess (110) for the nipple areola complex, an option for mid-body
support (112), and tabs (116) and (118) to allow the implant to
stretch over the breast mound without bunching.
[0039] FIGS. 10A to 10C show diagrams of a three-dimensional
implant for breast reconstruction. FIG. 10A shows a partial dome
shape of the implant, that is designed to contour and add shape to
the breast mound. FIG. 10B shows the width (W) of the partial dome,
and (80) shows the arch or edge of the dome viewed looking inside
the dome. FIG. 10C shows the height (H), depth (D), and angle
(.theta.) between the base (or floor) (84) of the partial dome and
the edge (82) of the partial dome at its highest point (86).
[0040] FIGS. 11A to 11C show a three-dimensional dome shaped
implant. FIG. 11A shows a three-dimensional partial dome shaped
implant (90) with three tabs (90a, 90b, 90c) for breast
reconstruction that is designed to contour and add shape to the
breast mound. FIG. 11B shows the width (W) of the partial dome and
placement of the tabs (90a, 90b, 90c). FIG. 11C shows the view of
the implant looking from above the partial dome. FIG. 11D shows the
height (H), depth (D), and angle (.theta.) between the base (or
floor) (92) of the partial dome and the edge of the partial dome at
its highest point (94).
[0041] FIG. 12A shows an example of how a three-dimensional partial
dome shaped implant, viewed from above, can be reinforced with body
ribbing (100) around the edge and body ribbing (102) in the
mid-dome region (102a and 102b) of the implant. FIG. 12B shows the
same three-dimensional implant as FIG. 12A, except viewed from
above and looking partially inside the dome.
DETAILED DESCRIPTION OF THE INVENTION
[0042] Ideally, it would be preferable to use an absorbable implant
for mastopexy and other breast reconstruction procedures that has a
longer strength retention profile, and the demonstrated ability to
regenerate healthy host tissue to support the breast. Such
regenerated host tissue could replace or reinforce the ligamentous
suspension system of the breast, acting as an artificial
suspensory, and release the skin from the function of maintaining
breast shape. The use of a prolonged strength retention absorbable
implant to provide an even suspension of the breast instead of
using sutures would also eliminate the formation of linear stress
lines associated with suture only breast lift techniques, as well
as eliminate the time required to adjust sutures to optimize
appearance. It would also be desirable to use minimally invasive
techniques in mastopexy and breast reconstruction procedures to
implant these absorbable implants.
[0043] Furthermore, it would be desirable to provide the surgeon
with a fully pre-shaped implant with shape memory and/or
self-expansion capability that can be temporarily deformed to allow
for implantation, and then resume its original preformed
three-dimensional shape after placement in a suitably dissected
tissue plane. The implant may be inserted in a folded, crimped, or
constrained conformation. After insertion in a suitably shaped
tissue plane, the implant would spring or open back into an opened
conformation of its own volition and due to its inherent design.
This procedure would be somewhat analogous in technique to a
standard breast augmentation procedure, wherein a small (1 to 3
inch) incision is created at the inframammary fold (IMF). This
incision is merely used by the surgeon as an access point through
which the surgeon dissects a much larger tissue plane into which
the implant is placed by deforming the implant and pushing it
through the (small) incision.
[0044] It should be noted that such shape memory implants would
differ substantially from other implants previously disclosed for
breast lift and reconstruction procedures. First, these shape
memory implants would have the ability to be temporarily deformed,
and then to open or spring into a shape after they are delivered in
vivo into a suitably shaped tissue plane. This property eliminates
the need for the surgeon to unroll, for example, a flat mesh after
implantation in vivo, and remove wrinkles in the mesh, and also
further enables minimally invasive procedures. Second, the shape
memory implants would be designed to confer shape to the breast
unlike other implants previously disclosed that must be shaped or
draped around the breast. Third, the shape memory implants are not
suspension devices that are suspended from the upper pole region
by, for example, sutures. Fourth, the shape memory implants are
self-reinforced to allow the implants to spring into shape or
deploy into an open conformation once implanted in vivo.
I. Definitions
[0045] "Absorbable" as generally used herein means the material is
degraded in the body, and the degradation products are eliminated
or excreted from the body. The terms "absorbable", "resorbable",
"degradable", and "erodible", with or without the prefix "bio", can
be used interchangeably herein, to describe materials broken down
and gradually absorbed, excreted, or eliminated by the body,
whether degradation is due mainly to hydrolysis or mediated by
metabolic processes.
[0046] "Bioactive agent" is used herein to refer to therapeutic,
prophylactic or diagnostic agents, preferably agents that promote
healing and the regeneration of host tissue, and also therapeutic
agents that prevent, inhibit or eliminate infection. Agent"
includes a single such agent and is also intended to include a
plurality.
[0047] "Bicomponent" as generally used herein means a structure
containing two or more materials.
[0048] "Blend" as generally used herein means a physical
combination of different polymers, as opposed to a copolymer formed
of two or more different monomers.
[0049] "Burst pressure" as used herein is determined according to
ASTM D6797-02 (Standard Test Method for Bursting Strength of
Fabrics Constant-Rate-of-Extension (CRE) Ball Burst Test) at
ambient conditions using a ball burst fixture with a 1.6 cm
circular opening and a 1 cm diameter half-rounded probe.
[0050] "Copolymers of poly-4-hydroxybutyrate" as generally used
herein means any polymer containing 4-hydroxybutyrate with one or
more different hydroxy acid units.
[0051] "Molecular weight" as used herein, unless otherwise
specified, refers to the weight average molecular weight (Mw), not
the number average molecular weight (Mn), and is measured by GPC
relative to polystyrene.
[0052] "Poly-4-hydroxybutyrate" as generally used herein means a
homopolymer containing 4-hydroxybutyrate units. It can be referred
to herein as P4HB or TephaFLEX.RTM. biomaterial (manufactured by
Tepha, Inc., Lexington, Mass.).
[0053] "Shape Memory" as used herein describes a property of the
implant that allows the user to squeeze, pull, roll up, fold up, or
otherwise deform the implant temporarily in order to facilitate its
insertion in the body wherein the device recovers its preformed
shape after insertion in the body.
[0054] "Self-reinforced" as used herein describes a property of the
implant in which the outer rim is strengthened such that the
implant can be squeezed, pulled, rolled, folded, or otherwise
temporarily deformed by the user to facilitate its insertion in the
body, and that allows the implant to recover its initial shape
after insertion in the body.
[0055] "Suture pullout strength" as used herein means the peak load
(kg) at which an implant fails to retain a suture. It is determined
using a tensile testing machine by securing an implant in a
horizontal holding plate, threading a suture in a loop through the
implant at a distance of 1 cm from the edge of the implant, and
securing the suture arms in a fiber grip positioned above the
implant. Testing is performed at a crosshead rate of 100 mm/min,
and the peak load (kg) is recorded. The suture is selected so that
the implant will fail before the suture fails.
[0056] "Taber Stiffness Unit" is defined as the bending moment of
1/5 of a gram applied to a 11/2'' (3.81 cm) wide specimen at a 5
centimeter test length, flexing it to an angle of 15.degree., and
is measured using a Taber V-5 Stiffness Tester Model 150-B or
150-E. The TABER.RTM. V-5 Stiffness Tester--Model 150-B or 150-E is
used to evaluate stiffness and resiliency properties of materials
up to 10,000 Taber Stiffness Units. This precision instrument
provides accurate test measurement to .+-.1.0% for specimens
0.004'' to 0.219'' thickness. One Taber Stiffness Unit is equal to
1 gram cm (g cm) or 0.0981 milliNewton meters (mN m). Taber
Stiffness Units can be converted to Genuine Gurley.TM. Stiffness
Units with the equation: S.sub.T=0.01419S.sub.G-0.935, where
S.sub.T is the stiffness in Taber Stiffness Units and S.sub.G is
the stiffness in Gurley Stiffness Units. To convert Taber Stiffness
Units to Millinewton Meters, use the equation: X=S.sub.T*0.098067,
where X is the stiffness in Millinewton Meters.
II. Implants
[0057] Poly-4-hydroxybutyrate (P4HB, TephaFLEX.RTM. biomaterial) is
a strong, pliable thermoplastic polyester that is biocompatible and
resorbable (Williams, et al. Poly-4-hydroxybutyrate (P4HB): a new
generation of resorbable medical devices for tissue repair and
regeneration, Biomed. Tech. 58(5):439-452 (2013)). Upon
implantation, P4HB hydrolyzes to its monomer, and the monomer is
metabolized via the Krebs cycle to carbon dioxide and water.
[0058] U.S. Pat. No. 8,034,270 to Martin et al. discloses methods
for making combination devices of P4HB with autologous, allogenic
and/or xenogenic tissues for use in mastopexy and breast
reconstruction, among other applications. WO 2011/119742 by Martin
et al. discloses PHA monofilament and multifilament fibers coated
with spin finish, and devices derived therefrom, including breast
reconstruction devices. There is no disclosure of specific designs
for use in these procedures, nor properties of these devices that
are necessary to regenerate host tissue strong enough to support
the breast and prevent recurrent ptosis. There is also no
disclosure of shape memory designs, and designs that allow the
implant to confer shape on the breast. Moreover, there is no
disclosure of implants that retain a three-dimensional shape
irrespective of whether the implant is placed in contact with a
three-dimensional part of the anatomy.
[0059] In order to prevent recurrent breast ptosis and aid in
shaping the breast parenchyma during a mastopexy or reduction
procedure, implants made of P4HB or other materials should have
strength retention times longer than one to two months that over
time can be replaced with regenerated host tissue, and that are
able to support the lifted breast mound/parenchyma (including
withstanding the forces exerted by any breast implant). The implant
should: (i) have mechanical properties sufficient to support the
breast, and any breast implant, while regenerated host tissue
develops; (ii) allow predictable tissue in-growth as the implant
slowly loses strength and is absorbed; (iii) have a strength
retention profile that allows a transition from support by the
implant to support by regenerated host tissue without any
significant loss of support; (iv) have a shape and design that (a)
is conformable to the breast and chest wall without buckling or
bunching, (b) has sufficient suture pullout strength to resist the
mechanical loads exerted on the reconstructed breast, (c) minimizes
the need to trim the implant during surgery, and (d) sculpts the
breast into the desired shape; (v) optionally possess shape memory
so that it can be temporarily deformed to allow for implantation
and resume its original preformed three-dimensional shape
essentially unaided; (vi) optionally have a 3-dimensional shape
that substantially represents the shape of the lower pole of the
breast, and (vii) optionally confer a shape to the breast.
[0060] Absorbable implants have been developed that are comprised
of scaffolds, which over time can be replaced with regenerated host
tissue that is able to support a surgically revised breast
(including withstanding the forces exerted by any breast implant).
The implants are preferably made from poly-4-hydroxybutyrate or
copolymer thereof. PHA fibers can be converted into meshes and
slings for breast reconstruction that allow some fibrous tissue
ingrowth, and yet are soft, supple, and barely palpable once
implanted.
[0061] The implants disclosed herein have mechanical properties
that are sufficient to support the load of the breast, and the
additional load of any breast implant, while regenerated host
tissue develops. Following implantation, the implant scaffold
structure allows a predictable in-growth of tissue as the implant
slowly loses strength and is absorbed. The scaffold has a prolonged
strength retention profile to ensure a smooth transition from
support of the breast by the implant to support of the breast by
regenerated host tissue without any significant loss of support. As
such, the implant can maintain the ideal shape of the operated
breast that was assembled during surgery.
[0062] A major advantage of these implants over existing mesh
assisted breast surgery and specifically mastopexy is that a
regenerated tissue that is strong enough to prevent recurrent
ptosis replaces the implants. This eliminates the problems and
concerns associated with the use of permanent or partially
absorbable meshes, such as contraction, long-term chronic
inflammatory and foreign body response and allows for long-term
changes in breast volume that can result from pregnancy and weight
gain or loss. The disclosed implants have major advantages over
prior approaches that have used absorbable polygalactin 910
(VICRYL.RTM.) meshes. The latter meshes undergo very rapid loss of
strength in vivo, and are completely absorbed in about 42 days.
This rapid absorption process provides little time for a
regenerated host tissue to form that can support the load on the
breast. In contrast, the P4HB implants have a prolonged strength
retention profile, and in a preferred embodiment can maintain some
residual strength for as much as one year. The prolonged presence
of these implants provides an extended period for tissue in-growth
into their scaffold structures, and a residual strength to prevent
early recurrent ptosis while the regenerated tissue forms.
Importantly, the in-grown tissue provides strength and support
beyond the time of complete strength loss of the implant, thus
demonstrating the implant's ability to provide a durable repair
beyond its absorption timeframe.
[0063] In an embodiment, the absorbable implants are designed so
that when manufactured, they are flat; however, when placed around
a breast, they have a shape that conforms to the contours of the
breast and chest wall without causing any buckling or bunching of
the implant or tissue structures. The implants are designed to help
sculpt the breast into the desired profile, and shaped to minimize
the need to trim the implants during surgery. In a particularly
preferred embodiment, the implants are asymmetric. In contrast,
absorbable meshes used in existing approaches have generally been
symmetric in shape. In a preferred embodiment, the asymmetric
shaped implants are made from poly-4-hydroxybutyrate or copolymer
thereof.
[0064] In another embodiment, the implants are designed to have
suture pullout strengths high enough to resist the initial
mechanical loads exerted by the breast, and to maintain sufficient
pullout strength while tissue in-growth occurs. In contrast,
polyglactin 910 (VICRYL.RTM.) rapidly loses strength, and has
negligible suture pullout strength after just a few days.
[0065] In a yet another embodiment, the implants are preformed
three-dimensional shapes with shape memory, designed to actively
provide shape to the lower pole of the breast parenchyma. The
implants can be temporarily deformed and resume their original
preformed shapes after implantation into a suitably dissected
tissue plane. The implants may aid in conferring a shape to the
breast, and are self-reinforced. In a preferred embodiment, the
three-dimensional shaped implants with shape memory are made from
poly-4-hydroxybutyrate or copolymer thereof.
[0066] A. Properties of the Implants
[0067] The absorbable implants have been designed to support the
mechanical forces acting on the breast during normal activities at
the time of implantation, and to allow a steady transition of
mechanical forces to regenerated host tissues that can also support
those same mechanical forces once the implant has degraded. Design
of the implant includes selection of the absorbable material, and
its form (such as mesh, film, foam), degree of orientation, and
molecular weight. This will also determine factors such as surface
area and porosity. At rest, the load exerted on a large breast
weighing, for example, 1 kg, is 9.8 Newtons (N). During exercise
where vertical acceleration can reach 2-3 g, or in extreme exercise
peak at around 6 g, the force on the breast could rise to nearly 60
N. In a preferred embodiment, the absorbable implants can withstand
a load of at least 5 N, more preferably of at least 15 N, and even
more preferably of at least 60 N.
[0068] Since the implants are absorbable, it is beneficial that the
implants be replaced with regenerated host tissue strong enough to
support the breast. In some embodiments, it is beneficial that the
implants contain a porous scaffold that can allow tissue in-growth,
and the formation of a regenerated tissue strong enough to support
the breast after the implant is degraded and absorbed. In an
embodiment, the scaffold structure of the implant has pore
diameters that are at least 50 .mu.m, more preferably at least 100
.mu.m, and most preferably over 250 .mu.m.
[0069] When the implant scaffold has been completely replaced by
regenerated host tissue, it must be able to support the breast. The
force per area that the regenerated tissue needs to be able to
withstand to prevent recurrent ptosis depends upon the size of the
reconstructed breast, activity level of the patient, and any
additional force exerted by a breast implant. In an embodiment, the
regenerated tissue supporting the reconstructed breast can
withstand a pressure of at least 0.1 kPa, more preferably at least
1 kPa, and even more preferably at least 5 kPa. In an even more
preferred embodiment, the combination of the implant and the
regenerating tissue forming in the implant scaffold can also
withstand a pressure of at least 0.1 kPa, more preferably at least
1 kPa, and even more preferably at least 5 kPa.
[0070] In a particularly preferred embodiment, the absorbable
implants are sutured in place. This means that although in theory
the load exerted by the breast is spread out over the implant, the
entire force of the breast tissue is shared among the points of
attachment of the implant to the body. A major advantage is that
the absorbable implants disclosed herein possess a high suture
pullout strength that allows a heavy breast to be supported with a
limited number of anchoring sites. The high suture pullout strength
can be obtained for example, as a result of selection of the
absorbable material, molecular weight, orientation, form (such as
monofilament mesh or film), and porosity.
[0071] In a preferred embodiment, a P4HB implant is anchored to the
chest wall at four or more places in order to support the breast.
This strategy distributes the load over multiple attachment points.
In a particularly preferred embodiment, the suture pullout strength
of the absorbable implant is greater than 10 N, and more preferably
greater than 20 N.
[0072] The implant can be designed either so that it stretches
equally in each direction, or it may stretch more in some
directions than in other directions. The ability of the implant to
stretch can allow the surgeon to place tension on the breast during
implantation. However, in order to maintain support for the breast
following surgery, it is critical that after the implant is
implanted, the implant, the regenerated host tissue, and any
transitional structures, cannot stretch significantly. In an
embodiment, the implant cannot stretch more than 30% of its
original length in any direction. In an even more preferred
embodiment, the implants cannot stretch more than 30% of their
original length in any direction and are made from
poly-4-hydroxybutyrate or copolymer thereof. This property is
imparted on the implant for example as a result of the degree of
orientation of the absorbable material, and also the weave or knit
pattern if it is a textile.
[0073] It is particularly important that the surgeon is able to
contour the implant to the surface of the breast parenchyma or
breast implant. It is also desirable that the implant is not
palpable through the skin once implanted. The implants have been
designed so that they are pliable, yet can remodel with increased
in-plane stiffness over time to keep the breast in the desired
shape. In a preferred embodiment, the implants are compliant and
have a Taber stiffness that is less than 100 Taber Stiffness Units,
more preferably less than 10 Taber Stiffness Units, and even more
preferably less than 1 Taber Stiffness Unit. The intrinsic property
of the absorbable material, degree of orientation and relaxation of
the polymer imparts on the implant the desired Taber Stiffness.
[0074] In a particularly preferred embodiment, the implant has
properties that allow it to be delivered through a small incision.
The implant may, for example, be designed so that it can be rolled
or folded to allow delivery through a small incision. This
minimally invasive approach can reduce patient morbidity, scarring
and the chance of infection.
[0075] In another preferred embodiment, the implant has a
three-dimensional shape and shape memory properties that allow it
to assume its original three-dimensional shape unaided after it has
been delivered through a small incision and into an appropriately
sized dissected tissue plane. For example, the implant may be
temporarily deformed by rolling it up into a small diameter
cylindrical shape, delivered using an inserter, and then allowed to
resume its original three-dimensional shape unaided in vivo. In
addition, the implant may be squeezed in between the fingers to
shorten the distance between the two furthest points of the implant
in order to facilitate its delivery through an incision smaller
than the width of the device.
[0076] B. Shapes
[0077] The implants can be prepared in sizes large enough to allow
for their use in mastopexy and other breast reconstruction
procedures such that they are wide enough to substantially span the
width of a breast, and for the surgeon to cut and trim the
implants, if and as necessary, to the required sizes and shapes. In
one embodiment, the implants are cut and shaped so that they can be
used in a mastopexy procedure (with or without a breast implant) or
in any other breast reconstruction procedure. In a preferred
embodiment, the implants are pre-cut and shaped so that they will
conform to the anatomical shape of the reconstructed breast. In
another embodiment, the implants can be cut and shaped to reinforce
breast tissues, and in particular so that there is no buckling or
bunching of the implant. In still another embodiment, the implants
are two-dimensional (i.e. flat), but can be formed around
three-dimensional shapes without any buckling or bunching of the
implant.
[0078] In yet another embodiment, the implants are designed so that
they can help to sculpt breast parenchyma into the desired shape.
In a particularly preferred embodiment, the implants have
anatomical shapes, three-dimensional shapes, and/or asymmetric
shapes. These shapes minimize the need to cut or trim the implant
during use, and also minimize any buckling or bunching of the
implant.
[0079] Non-limiting examples of a support include a mesh, a set of
strips, a fabric, a woven construct, a non-woven construct, a
knitted construct, a braided construct, a porous scaffold, a porous
film including laminated and perforated film, a nanospun,
electrospun, or melt-blown construct.
[0080] The implants can incorporate one or more tabs to accommodate
suture throws or other anchoring devices for the fixation of the
implant to the patient's tissues. These tabs can be placed in order
to improve the implant's ability to conform and shape to the
breast, as well as to adapt to the chest wall. In particular, these
tabs can be incorporated with appropriate spacing into the implant
so that they amplify the implant's ability to bend and stretch
around the lower curvature (lower pole) of the breast without
causing bunching, kinking, folding or wrinkling of the implant.
[0081] Asymmetric Implants
[0082] In one embodiment shown in FIG. 1, a body 10 of the
asymmetric implant is shaped into a teardrop. This shape helps to
prevent the implant from buckling or bunching, minimizes the need
to cut or shape the implant during surgery, provides a low profile
to avoid coverage of the nipple-areolar complex, and facilitates
sculpturing the breast to create enhanced cleavage. Tabs 12, 14,
16, 18 or other shapes can also protrude from the teardrop, for
example, to accommodate suture throws or other anchoring devices,
maximize load distributions, and further shape the contours of the
reconstructed breast. These tabs also allow the implant to contour
tightly to the breast mound without forming wrinkles or folds. In a
preferred embodiment, the width to height ratio of the teardrop
ranges from a ratio of 10:1 to 1.5:1, and is more preferably 5:2.
For example, the width (W) of the teardrop implant (shown in FIG.
1) can be about 25 cm and the height (H) of the teardrop shown in
FIG. 1) can be 10-11 cm as. (The width of the teardrop is the
longest distance measured between any two points, and the height of
the teardrop is the longest distance measured perpendicular to the
width.) With reference to FIG. 1, four tabs are shown extending
from body 10.
[0083] Two tabs 12, 14 are shown extending from a base or wider
portion of the teardrop, and an additional two tabs 16, 18 are
shown extending from the narrow or tip portion of the tear drop.
The tabs are shown in an asymmetric arrangement. Tabs assist with
contouring to the breast tissue, and providing a platform for
fastening the implant to tissue. Although four tabs are shown in
FIG. 1, the body 10 may include more or less than four tabs.
Preferably, the implant includes at least 4 tabs.
[0084] As described herein, the implant combines various features
to optimize mechanical properties. For example, various
combinations of implant body shapes, tab shapes, tab locations,
number of tabs, thickness of body, type of material, and material
processing result in increased mechanical properties including but
not limited to increased suture pull out strength, increased breast
load, increased stiffness, and increased load after several months
(e.g. increased load after 78 weeks).
[0085] The implant may be installed in either breast. The implant
shown in FIG. 1 is suited for a mastopexy procedure.
[0086] In a particularly preferred embodiment, the teardrop can
incorporate seam lines that can be embossed to project the
two-dimensional structure of the implant into a three-dimensional
structure that accentuates the breast contouring.
[0087] In another embodiment, the asymmetric implant is shaped as
shown in FIG. 2, and used to reconstruct a right breast. An implant
with a shape that is the mirror image of FIG. 2 may be used to
reconstruct a left breast. The implant optionally has a curved
mid-body support (90) to improve breast mound contouring and
support, cut notches (92) and tabs (94) to minimize stress
concentrations and allow the implant to stretch over the breast
mound with minimal bunching. The notched sections may, if desired,
be stitched closed to create a three-dimensional cup shape. In an
embodiment, the implant has a width (W) between 22 and 30 cm, a
height (H) between 7.5 and 11 cm, a perimeter notch gap (N.sup.1)
between 0.5 and 4 cm, and a tab width (N.sup.2) between 1 and 2
cm.
[0088] The implants of FIGS. 1 and 2 can be manufactured using a
metal form and standard manufacturing techniques. FIG. 3 is a
diagram of a split metal form (20), including an inwardly curving
half (22) and a mating outwardly curving half (24) with a
semicircular groove (26) in the outlying border of the inwardly
curving half (28), which is used to make implants that can assume a
three-dimensional shape unaided. A line in the outwardly curving
half (30) designated by the letters "AA" denotes the position of a
cross-section view (32) of the outwardly curving half of the mold
(204). A material (210) to be molded is sandwiched in the split
metal mold.
[0089] When the shape of the three-dimensional implant is
substantially a hemi-ellipsoid, the dimensions of the implant may
be defined by the tri-axial dimensions "a", "b" and "c" shown in
FIGS. 4A and 4B. In a preferred embodiment, the ranges of these
dimensions are preferably "a" from 2 to 10 cm, "b" from 3 to 10 cm,
and "c" from 2.5 to 12 cm.
[0090] Shaped Implants
[0091] One embodiment of a two-dimensional implant is shown in FIG.
5. The upper region (40) of the implant has a larger footprint than
the lower region (or tab) (46) of the implant, and is designed to
support the breast parenchyma by spreading the load to key
anchoring points. The implant features deep in cuts (48) that allow
the lower region (or tab) (42) to fold at the IMF (i.e. at the
dashed line in FIG. 7) and give shape to the IMF without bunching
of the implant. The implant shown in FIG. 5 also incorporates
rounded corners (e.g. (46)) to eliminate stress concentrations in
the implant. In a preferred embodiment, the width (W) of the
implant shown in FIG. 5 is between 18 cm and 36 cm, and the height
(H) of the implant is between 6 cm and 14 cm.
[0092] Another embodiment of a two-dimensional implant is shown in
FIG. 6. The upper region (52) of the implant also has a larger
footprint than the lower region (or tab) (50) of the implant, and
is also designed to support the breast parenchyma by spreading the
load to key anchoring points. Instead of incorporating deep in
cuts, the implant has a curved upper line (54) to allow the implant
to conform and support the breast parenchyma without the implant
bunching. The implant shown in FIG. 6 also incorporates rounded
corners (56) and (58) to eliminate stresses in the implant. An
oblong-shaped tab (50) allows the implant to fold at the IMF (i.e.
at the dashed line in FIG. 6) and give shape to the IMF and support
to the vertical pillar. In contrast to the implant shown in FIG. 5,
the implant shown in FIG. 6 has a shorter width or span from left
to right to anchor the implant on the breast mound. In a preferred
embodiment, the width (W) of the implant shown in FIG. 6 is between
10 cm and 26 cm, and the height (H) of the implant is between 6 cm
and 14 cm.
[0093] A further embodiment of the two-dimensional implant is shown
in FIG. 7. The implant has a curved upper line (70) (like the
implant of FIG. 6) to allow the implant to conform to the breast
without bunching, and a wide left to right span (like the implant
of FIG. 5) to facilitate sling support of the breast parenchyma.
The implant has a bottom tab (76) to anchor the implant and support
the breast vertical pillar, and side tabs (e.g. (72)) separated
from the bottom tab (76) with inset cuts to allow the implant to
flex between tabs and form a curved IMF. The implant also features
rounded corners to eliminate stress concentrations in the implant.
In a preferred embodiment, the width (W) of the implant shown in
FIG. 7 is between 18 cm and 34 cm, and the height (H) of the
implant is between 8 cm and 16 cm.
[0094] The implants may also be crescent-shaped, rectangular or any
other shape. As a crescent shape, the implant can transition from a
first low profile or rolled configuration to a deployed shape. The
implant can also be a canoe-like body including walls and a cavity
formed therein. The cavity serves to accommodate the breast
parenchyma when deployed. The implant can be configured as a sheet,
a solid sheet, or as a discontinuous layer such as a mesh.
[0095] An example of a crescent shaped implant is shown in FIG. 8.
In a preferred embodiment, the crescent shaped implant has a width
(W) of 10 to 25.5 cm, and a height (H) of 5 to 11 cm.
[0096] Another example of an implant with an upper curving profile
is shown in FIG. 9. The two-dimensional implant incorporates a
recess (110) for the nipple areola complex (NAC), an option for
mid-body support (112), and notches (114) that create tabs (116)
and (118) so that the implant can be stretched over the breast
mound without bunching of the implant. The notched sections may
also be stitched closed to create a three-dimensional cup shape.
The mid-body support (112) may be stitched or embossed to create a
hinge or crease. In an embodiment, the implant (900) has a width
(W) between 22 and 30 cm, a height (H.sup.1) between 8.5 and 13 cm,
a height (H.sup.2) between 6.5 and 11 cm, a perimeter notch gap
(N.sup.1) between 0.5 and 4 cm, and a tab width (N.sup.2) between 1
and 2 cm.
[0097] Three-Dimensional Shaped Implants
[0098] The disclosed implants include embodiments with a
three-dimensional shape that is designed to provide additional
predetermined contour to the host's breast tissue or an anatomical
structure of the breast. In an embodiment shown in FIG. 10, the
implant has a three-dimensional partial dome shape (i.e. FIG. 10A)
that allows the implant to capture, contour, and support the breast
parenchyma, and distribute the load to key anchoring positions. The
ability of the implant to capture and contour the breast parenchyma
(i.e. the 3D implant mates and molds with the 3D breast mound)
reduces surgery time. In common with the implants of FIGS. 5 and 6,
the implant of FIG. 10A-C has rounded corners to eliminate stress
concentrations in the implant and prevent bunching of the implant.
In a preferred embodiment, the width (W) of the implant shown in
FIG. 10B is between 12 and 24 cm, the height (H) measured from the
floor or base (84) of the dome to the highest point (86) shown in
FIG. 10C is between 2 and 10 cm, and the depth (D) of the dome
shown in FIG. 10C is between 2.5 cm and 10 cm. The angle .theta.
shown in FIG. 10C is preferably between 30.degree. and
90.degree..
[0099] In a preferred embodiment, tabs may be added to the implant
shown in FIG. 10A-C, for example, as shown in FIG. 11A-B. In the
embodiment shown in FIG. 11A, the partial dome implant includes 3
tabs (90a, 90b and 90c), placed at the bottom of the implant (i.e.
in the middle, 90a) and at the right and left sides (90b and 90c).
In a preferred embodiment, the width (W) of the implant shown in
FIGS. 11A-D is between 12 and 24 cm, the height (H) measured from
the floor or base of the dome (92) to the highest point (64) shown
in FIG. 8D is between 2 and 10 cm, and the depth (D) of the dome
shown in FIG. 8D is between 2.5 cm and 10 cm. The angle .theta.
shown in FIG. 8D is preferably between 30.degree. and 90.degree..
Optionally, a support rib can be added to the inner surface of the
partial dome implants shown in FIGS. 10 and 11 to provide added
support and, if necessary, rigidity, or to add shape retention to
the implant (for example, to allow minimally invasive delivery of
the implant). An example of an implant with a three-dimensional
partial dome shape that has been reinforced with ribbing is shown
in FIG. 12. In this example, the partial dome shaped implant is
reinforced with body ribbing along the perimeter (100) of the dome
and in the mid-dome (102a and 102b) section.
[0100] Implants with Shape Memory
[0101] The three-dimensional shaped implants disclosed herein
include implants that have shape memory. The shape memory allows
the implant to be temporarily deformed, delivered by a minimally
invasive method, and resume its preformed three-dimensional shape
once placed across the lower pole of the breast. A particularly
preferred three-dimensional shape comprises an outwardly curving
exterior, and an inwardly curving interior. An even more preferred
three-dimensional shape is self-reinforced and comprises an
outwardly curving exterior, an inwardly curving interior, and an
outlying border that is reinforced by a continuous or interrupted
ring. The continuous or interrupted ring allows the implant to
assume the desired three-dimensional shape unaided even if the
three-dimensional shape has been temporarily deformed, for example,
by rolling it into a small diameter cylinder or manipulating it
into some other configuration. The three-dimensional shapes with
shape memory may vary in shape and size. Shapes include, but are
not limited to, hemispheres, hemi-ellipsoids, domes or similar
kinds of shapes. The sizes of the three-dimensional shapes with
shape memory vary, and range, for example, from a width of 8 to 20
cm at the base, more preferably 8 to 17 cm at the base, and a
height or radius of curvature of 5 to 10 cm. In an embodiment, the
width of the three-dimensional shape is designed to be 1 to 2 cm
less than the width of the patient's breast after mastopexy. In
another embodiment, the height of the three-dimensional shape is
0.5 to 2 cm less than the patient's nipple-IMF distance after
mastopexy.
[0102] Non-limiting examples of materials that may be used to make
these three-dimensional shaped implants with shape memory include
meshes (e.g. monofilament and multifilament knitted meshes),
strips, fabrics, woven constructs, non-woven constructs, knitted
constructs, braided constructs, porous scaffolds, laminates,
nanospuns, electrospuns, dry spuns, or melt-blown constructs,
filaments, threads, strands, strings, fibers, yarns, wires, films,
tapes, felts, multifilaments and monofilaments.
[0103] C. Polymers
[0104] Any absorbable biocompatible polymer may be used to make the
implants provided the implant has sufficient initial strength to
shape and support the reconstructed breast, undergoes a controlled
resorption process in the breast, and is replaced with regenerated
host tissue that can support the breast. The implant may, for
example, be prepared from polymers including, but not limited to,
polymers of glycolic acid, lactic acid, 1,4-dioxanone, trimethylene
carbonate, 3-hydroxybutyric acid, .epsilon.-caprolactone, including
polyglycolic acid, polylactic acid, polydioxanone,
polycaprolactone, copolymers of glycolic and lactic acids, such as
VICRYL.RTM. polymer, MAXON.RTM. and MONOCRYL.RTM. polymers, and
including poly(lactide-co-caprolactones); poly(orthoesters);
polyanhydrides; poly(phosphazenes); polyhydroxyalkanoates;
synthetically or biologically prepared polyesters; polycarbonates;
tyrosine polycarbonates; polyamides (including synthetic and
natural polyamides, polypeptides, and poly(amino acids));
polyesteramides; poly(alkylene alkylates); polyethers (such as
polyethylene glycol, PEG, and polyethylene oxide, PEO); polyvinyl
pyrrolidones or PVP; polyurethanes; polyetheresters; polyacetals;
polycyanoacrylates; poly(oxyethylene)/poly(oxypropylene)
copolymers; polyacetals, polyketals; polyphosphates;
(phosphorous-containing) polymers; polyphosphoesters; polyalkylene
oxalates; polyalkylene succinates; poly(maleic acids); silk
(including recombinant silks and silk derivatives and analogs);
chitin; chitosan; modified chitosan; biocompatible polysaccharides;
hydrophilic or water soluble polymers, such as polyethylene glycol,
(PEG) or polyvinyl pyrrolidone (PVP), with blocks of other
biocompatible or biodegradable polymers, for example,
poly(lactide), poly(lactide-co-glycolide, or polycaprolactone and
copolymers thereof, including random copolymers and block
copolymers thereof. Blends of polymers can also be used to prepare
the implants. Preferably the polymer or copolymer will be
substantially resorbed within a 6 to 18 month timeframe, and retain
some residual strength for at least 1-2 months, and more preferably
at least 6 months.
[0105] In a particularly preferred embodiment,
poly-4-hydroxybutyrate (P4HB) or a copolymer thereof is used to
make the implant. Copolymers include P4HB with another hydroxyacid,
such as 3-hydroxybutyrate, and P4HB with glycolic acid or lactic
acid monomer. In a preferred embodiment, the P4HB homopolymer and
copolymers thereof have a weight average molecular weight, Mw,
within the range of 50 kDa to 1,200 kDa (by GPC relative to
polystyrene) and more preferably from 100 kDa to 600 kDa. A weight
average molecular weight of the polymer of 50 kDa or higher is
preferred for prolonged strength retention.
[0106] D. Coatings to Stimulate Cell Attachment and in-Growth
[0107] The implants can be coated, derivatized, or modified with
other agents in order to improve wettability, water contact angle,
cell attachment, tissue in-growth, and tissue maturation.
[0108] In one embodiment, the implants can contain cellular
adhesion factors, including cell adhesion polypeptides. As used
herein, the term "cell adhesion polypeptides" refers to compounds
having at least two amino acids per molecule that are capable of
binding cells via cell surface molecules. The cell adhesion
polypeptides include any of the proteins of the extracellular
matrix which are known to play a role in cell adhesion, including
fibronectin, vitronectin, laminin, elastin, fibrinogen, collagen
types I, II, and V, as well as synthetic peptides with similar cell
adhesion properties. The cell adhesion polypeptides also include
peptides derived from any of the aforementioned proteins, including
fragments or sequences containing the binding domains.
[0109] In another embodiment, the implants can incorporate wetting
agents designed to improve the wettability of the surfaces of the
implant structures to allow fluids to be easily adsorbed onto the
implant surfaces, and to promote cell attachment and/or modify the
water contact angle of the implant surface. Examples of wetting
agents include polymers of ethylene oxide and propylene oxide, such
as polyethylene oxide, polypropylene oxide, or copolymers of these,
such as PLURONICS.RTM.. Other suitable wetting agents include
surfactants or emulsifyers.
[0110] E. Therapeutic, Prophylactic and Diagnostic Agents
[0111] The implants may contain bioactive agents.
[0112] In a preferred embodiment, the agents improve cell
attachment, tissue in-growth, and tissue maturation. The implants
can contain active agents designed to stimulate cell in-growth,
including growth factors, cellular differentiating factors,
cellular recruiting factors, cell receptors, cell-binding factors,
cell signaling molecules, such as cytokines, and molecules to
promote cell migration, cell division, cell proliferation and
extracellular matrix deposition. Such active agents include
fibroblast growth factor (FGF), transforming growth factor (TGF),
platelet derived growth factor (PDGF), epidermal growth factor
(EGF), granulocyte-macrophage colony stimulation factor (GMCSF),
vascular endothelial growth factor (VEGF), insulin-like growth
factor (IGF), hepatocyte growth factor (HGF), interleukin-1-B (IL-1
B), interleukin-8 (IL-8), and nerve growth factor (NGF), and
combinations thereof.
[0113] Other bioactive agents include antimicrobial agents, in
particular antibiotics, disinfectants, oncological agents,
anti-scarring agents, anti-inflammatory agents, anesthetics, small
molecule drugs, anti-angiogenic factors and pro-angiogenic factors,
immunomodulatory agents, and blood clotting agents.
[0114] The bioactive may be proteins such as collagen and
antibodies, peptides, polysaccharides such as chitosan, alginate,
polysaccharides such as hyaluronic acid and derivatives thereof,
nucleic acid molecules, small molecular weight compounds such as
steroids, inorganic materials such as hydroxyapatite, or complex
mixtures such as platelet rich plasma. Suitable antimicrobial
agents include: bacitracin, biguanide, trichlosan, gentamicin,
minocycline, rifampin, vancomycin, cephalosporins, copper, zinc,
silver, and gold. Nucleic acid molecules may include DNA, RNA,
siRNA, miRNA, antisense or aptamers.
[0115] Diagnostic agents include contrast agents, radiopaque
markers, or radioactive substances which may be incorporated into
the implants.
[0116] The implants may also contain allograft material and
xenograft materials. In yet another preferred embodiment, the
implants may incorporate systems for the controlled release of the
therapeutic or prophylactic agents.
II. Methods of Manufacturing Implants
[0117] A variety of methods can be used to manufacture the
implants, and their scaffold structures. The methods must, however,
allow the construction of implants that can: (i) withstand a load
of at least 5 N, (ii) support a pressure of at least 0.1 kPa, and
(iii) hold a suture with a pullout strength exceeding 10 N. In one
embodiment, the porous scaffolds are prepared using a process that
incorporates particulate leaching. This process allows the size and
porosity of the scaffold to be controlled by careful selection of
the size of the leachable material and its distribution. The
scaffolds can be prepared by dispersing particles of the leachable
material in a solution of a biocompatible absorbable polymer,
wherein the leachable material is not soluble in the polymer
solvent. In a preferred embodiment, the leachable particle
materials have a diameter of at least 25 .mu.m, and more preferably
greater than 50 .mu.m. The leachable particles must be non-toxic,
easily leached from the polymer, non-reactive with the polymer, and
biocompatible (in case residues are left in the scaffold after
leaching). In a preferred embodiment, the leachable particles are
water soluble, and can be leached from the polymer solution with
water. Examples of suitable particles include salts such as sodium
chloride, sodium citrate, and sodium tartrate, proteins such as
gelatin, and polysaccharides such as agarose, starch and other
sugars. Examples of suitable solvents for the polymers include
tetrahydrofuran, dioxane, acetone, chloroform, and methylene
chloride. In a particularly preferred embodiment, an implant
comprising a porous scaffold is formed from P4HB by adding salt
particles (100-180 .mu.m diameter) to a solution of the polymer in
dioxanone (10% wt/vol), allowing the solvent to evaporate, pressing
the mixture using a hydraulic press with heated platens, and
leaching out the salt particles after the polymer has
crystallized.
[0118] In another embodiment, a process that includes phase
separation is used to form the porous scaffold. The size of the
pores can be selected by varying parameters such as the solvent,
and the concentration of the polymer in the solvent. Suitable
solvents include tetrahydrofuran, dioxane, acetone, chloroform, and
methylene chloride. In a particularly preferred embodiment, a cast
solution of P4HB dissolved in dioxane (3% wt/vol) is frozen at
-26.degree. C. to precipitate the polymer, and the solvent
sublimated in a lyophilizer to form a phase separated porous P4HB
scaffold.
[0119] In a further embodiment, the scaffolds can be prepared from
films. The films are made by either solvent casting or melt
extrusion. The films can be un-oriented, or more preferably
oriented in one or more directions so that they have sufficient
mechanical properties to support the breast, and provide prolonged
strength retention. In order to allow tissue in-growth, the films
must be rendered porous or attached to other porous components.
Suitable methods for making the films porous include punching or
laser drilling holes in the films, or cutting slits or holes in the
films. In a particularly preferred embodiment, porous scaffolds are
prepared by melt extrusion of P4HB films, and holes are cut,
punched or drilled in the films.
[0120] In still another embodiment, the scaffold can comprise
thermally bonded fibers. The thermally bonded fibers can be
produced by melt extrusion using a multi-holed die. This process
allows the diameter of the fibers, the porosity of the scaffold,
and the thickness of the scaffold to be controlled by selection of
parameters such as the diameter of the die holes, the distance
between the die and collector plate, and the collection time. In a
preferred embodiment, the thermally bonded fiber scaffold has one
or more of the following properties (i) a thickness of 0.1-5 mm,
(ii) an areal density or basis weight of 5 to 800 g/m.sup.2, (iii)
a suture pullout strength of greater than 10 N, and (iv) is able to
withstand a pressure of at least 0.1 kPa. In a preferred
embodiment, the scaffold is formed from thermally bonded P4HB
fibers.
[0121] The scaffolds can also be formed from structures comprising
non-wovens that have been prepared by entangling fibers using
mechanical methods. The properties of the nonwovens can be tailored
by selection of parameters such as fiber diameter, fiber
orientation, and length of the fibers (for staple nonwovens). In a
preferred embodiment, the scaffolds comprising non-wovens have one
or more of the following properties (i) a thickness of 0.1-5 mm,
(ii) an areal density of 5 to 800 g/m.sup.2, (iii) a suture pullout
strength of greater than 10 N, and (iv) is able to withstand a
pressure of at least 0.1 kPa. In a preferred embodiment, the
scaffold is formed from a P4HB non-woven.
[0122] The scaffolds may also be formed directly from solution by
spinning processes. In these processes, solutions are pumped or
forced through dies, and fibers are collected after removal of the
polymer solvent. The fiber diameters and porosities of the
scaffolds can be controlled by appropriate selection of parameters
such as the solvent, temperature, pump pressure or force, die
configuration, and the diameter of the holes in the die. In the
case of wet spinning, the choice of coagulation non-solvent may be
used to control fiber diameter and scaffold porosity and
morphology. In a preferred embodiment, the solution spun scaffolds
have (i) a thickness of between about 0.5 and 5 mm, (ii) a weight
of between 5 and 800 g/m.sup.2, (iii) a suture pullout strength of
greater than 10 N, and (iv) are able to withstand a pressure of at
least 0.1 kPa. In a preferred embodiment, the scaffold is formed
from solution spun P4HB fibers.
[0123] In yet another embodiment, the scaffolds can be prepared
from monofilament fibers, multifilament fibers, or a combination of
these fibers. Melt extrusion and solution spinning processes can be
used to form these fibers. In a preferred embodiment, the scaffolds
are woven or knitted from the pre-formed fibers. The scaffolds may
be produced by either warp or weft knitting processes, however, a
warp knit is preferred in order to minimize the stretching of the
scaffold structure. In a preferred embodiment, the scaffold woven
from mono or multifilament fibers has one or more of the following
properties: (i) stretches less than 30% of the scaffold's original
length in any direction, (ii) has a suture pullout strength of at
least 10 N, and (iii) can withstand a pressure of at least 0.1 kPa.
In a particularly preferred embodiment, the scaffold is made from
P4HB monofilament fibers, P4HB multifilament fibers, or a
combination of these fibers, and has an areal density of 5 to 800
g/m.sup.2. The implant can also be prepared by combining a woven or
knitted P4HB construct with a P4HB film.
[0124] In still another embodiment, the scaffolds may be prepared
by methods that include 3D printing (also known as additive
manufacturing). This method is particularly useful in the
manufacture of specific shapes since the desired shape can be made
directly without the need for further cutting or trimming.
[0125] In still a further embodiment, the scaffolds may be prepared
by molding. In these processes, polymer may be directly molded into
a scaffold, or the polymer may be first converted into another form
(such as a mesh, film, non-woven, laminate, electrospun fabric,
foam, thermoform or combinations thereof), and then the form
molded, or two methods may be used to form a scaffold that has
varying stiffness. In a preferred embodiment, three-dimensional
shapes with shape memory are prepared by molding a monofilament
mesh into a shape designed to confer shape to the host's breast
tissue or form an anatomical shape of the breast. Such shapes
include those with an outwardly curving exterior and inwardly
curving interior, and optionally contain an outlying border that is
reinforced by a continuous or interrupted ring that allows the
three-dimensional scaffold to be temporarily deformed and resume a
three-dimensional shape. (Such shapes have shape memory.) Shapes
with outwardly curving exteriors and inwardly curving interiors
may, for example, be prepared using a split metal form consisting
of an inwardly curving half and a mating outwardly curving half as
shown in FIG. 3. One skilled in the art will understand that the
size and shape of the split metal form can be varied in order to
provide different three-dimensional shapes that can confer shape to
a patient's breast. In a preferred embodiment, the inwardly curving
half of the metal form contains a semicircular groove in the
outlying border that will accommodate a continuous or interrupted
ring of filament, thread, strand, string, fiber, yarn, wire, film,
tape, tube, fabric, felt, mesh, multifilament or monofilament. In a
particularly preferred embodiment the groove will accommodate a
monofilament, preferably a monofilament extrudate. The semicircular
groove is cut into the outlying border of the inwardly curving half
such that the ring of material, for example, a monofilament, will
protrude from the groove. In an alternative embodiment, the groove
may be cut into the outwardly curving half instead of the inwardly
curving half. A three-dimensional shape with an inwardly curving
interior, outwardly curving exterior, and reinforced outlying
border is prepared by placing, for example, a filamentous or other
extrudate in the semicircular groove of the inwardly curving half
so that it forms a ring, draping a polymeric material such as a
monofilament mesh over the inwardly curving half of the metal form,
placing the mating outwardly curving half of the metal form over
the polymeric material, and clamping the two halves of the split
metal form together to form a block. The block is then heated,
cooled, disassembled, and the three-dimensional shape removed and
trimmed as necessary to form a smooth outlying border. In an
embodiment, the block is heated uniformly, preferably by heating
with hot water, and cooled uniformly, preferably by cooling with
ambient temperature water. In a preferred embodiment, the
three-dimensional shape is made from a poly-4-hydroxybutyrate
monofilament mesh, and a poly-4-hydroxybutyrate monofilament
extrudate. The temperature of the hot water is set such that the
ring is either pressed or melted into the outlying border to
reinforce the outlying border. When the three-dimensional shape is
made from poly-4-hydroxybutyrate, the temperature of the hot water
is set at approximately 56.degree. C., and the polymer construct is
heated for approximately 5 minutes. We have discovered that
provided a ring of polymer, derived, for example, from a
poly-4-hydroxybutyrate monofilament extrudate, is used to reinforce
the outlying border of the poly-4-hydroxybutyrate scaffold, the
scaffold can be temporarily deformed for implantation, and will
then resume its three-dimensional shape when released in a suitably
dissected tissue plane. However, if a ring is not used to reinforce
the edge of the poly-4-hydroxybutyrate material (such as a
monofilament mesh), the poly-4-hydroxybuyrate material will not be
able to resume a three-dimensional shape.
[0126] In another embodiment, the implants comprise retainers, such
as barbs or tacks, so that the implant can be anchored to the chest
wall without the use of additional suture. For example, the
three-dimensional implants may contain retainers in their outlying
borders to anchor the implants.
[0127] The implants can be cut or trimmed with scissors, blades,
other sharp cutting instruments, or thermal knives in order to
provide the desired shapes. The implants can also be cut into the
desired shapes using laser-cutting techniques. This can be
particularly advantageous in shaping fiber-based implants because
the technique is versatile, and importantly can provide shaped
products with sealed edges that do not shed cut loops or debris
produced in the cutting process.
[0128] The processes described herein to produce the scaffolds can
also be used in combination. For example, a woven construct could
be combined with a non-woven construct to make a scaffold. In a
preferred embodiment, a scaffold can be reinforced with a
monofilament or multifilament fiber. In a particularly preferred
embodiment, the implants can be reinforced at anchor points to
provide, for example, increased suture pullout strength.
III. Methods of Implanting
[0129] The implants are most suited to use in mastopexy or
mastopexy augmentation procedures, wherein the skin of the lower
pole is dissected away from the breast and eventually tightened to
provide a more appealing breast contour. However, the implants may
also be used in other procedures such as revision procedures
following the removal of a breast implant, and breast
reconstruction procedures following mastectomy, particularly where
it is desirable to retain the position of a silicone or saline
breast implant or tissue expander. For example, the implants may be
used on the lateral side of a patient's breast to properly retain a
breast implant, or to cover a breast implant. The implants may also
be used in conjunction with expanders in breast reconstruction
procedures to give additional support for the skin surrounding an
expander, and to create a pocket for a breast implant. They may
also be implanted to cover any defects in the major pectoralis
muscle, after insertion of breast implants, in patients undergoing
breast reconstruction where the muscle has been compromised as a
result of breast cancer and mastectomy.
[0130] Any current mastopexy technique may be used to achieve a
breast lift with the implants using any appropriate skin resection
pattern, provided it preserves the functional integrity of the
mammary structures. The implants can also be implanted using
minimally invasive techniques such as those disclosed by U.S.
Patent Application No. 20120283826 to Moses et al.
[0131] The chosen method will depend upon the extent of breast
ptosis and a number of other factors. The four main techniques for
mastopexy are the: crescent mastopexy, donut (or Benelli)
mastopexy, lollipop (or vertical) mastopexy, and anchor (or Weiss
or Wise) mastopexy. In the crescent mastopexy, a semi-circular
incision is made on the upper side of the areolar, and a crescent
shaped piece of breast tissue removed. This procedure is typically
used for patients with only mild ptosis where a good lift can be
achieved by removing excess skin on the upper breast, and suturing
the skin back in order to elevate the areolar nipple complex. In
one embodiment, the implants can be implanted after further
dissection and/or resection to provide additional support for the
upper breast tissue.
[0132] The implants can also be implanted during a donut or Benelli
mastopexy. In this procedure, a donut shaped piece of breast skin
is removed from around the areolar with an inner incision line
following the perimeter of the areolar, and an outer incision line
circling the areolar further out. In one embodiment, the implant(s)
can be inserted after further dissection to support the lift, and a
purse string suture used to approximate the breast skin back to the
areolar.
[0133] In both the lollipop and anchor mastopexy procedures,
incisions are made around the areolar complex. In the lollipop
procedure, a vertical incision is made in the lower breast from the
areolar to the inframammary fold, and in the anchor mastopexy
procedure an incision is made across the inframammary fold in
addition to the vertical incision used in the lollipop procedure.
The lollipop procedure is generally used for patients with moderate
ptosis, whereas the anchor procedure is normally reserved for
patients with more severe ptosis. These two procedures can be
performed with or without breast implant augmentation. In both
procedures, breast tissue may be resected, and the resected edges
sutured together to create a lift. Prior to suturing the resected
tissue, the implants can be implanted to support the breast, and to
decrease the forces on the resected skin and suture line after
closure. In a particularly preferred procedure, the implants are
positioned to support the breast parenchyma or implant, and to
minimize the weight of the breast on the skin and suture line. In
an even more preferred procedure, the suture line is closed with
minimal or no tension on the wound to minimize scar formation.
[0134] In a preferred embodiment, when sutured in place, the
implants provide support, elevation and shape to the breast by
anchoring of the implants at one or more locations to the tissue,
muscle, fascia or the bones of the chest or torso. In a
particularly preferred embodiment, the implants are sutured to the
pectoralis fascia or the clavicle. The implants may also be sutured
to the chest wall or fascia, and in a particularly preferred
embodiment, the implants may be sutured to the chest wall so that
they provide slings for support of the lifted breast or breast
implant.
[0135] The teardrop implant of FIG. 1 is designed to be implanted
with the wider section positioned medially for primary load
support, and the tapered section positioned on the side of the
chest near the arm for lateral support and to direct the breast to
the cleavage area. Thus in a preferred embodiment, the implant is
asymmetric, and has a precise geometric form. The implant may be
anchored first in the medial position using the two suture tabs
located in the wider section of the implant, and then the tapered
end of the implant subsequently anchored, preferably under tension.
Tabs are shown in FIG. 1 having a length to width ratio ranging
from about 1:1 to 1:2. However, the shape and size of the tabs may
vary widely and are only intended to be limited as recited in the
appended claims.
[0136] In a preferred embodiment, the three-dimensional implants
with shape memory are implanted using minimally invasive techniques
into a suitably dissected tissue plane to confer shape to the
breast. These implants may, for example, be rolled up into a small
cylindrical shape, placed inside a tubular inserter, and implanted
through a small incision, such as a standard size incision at the
inframammary fold that is usually used for breast augmentation.
Once released in vivo, these implants will resume their original
three-dimensional shapes, and may be moved into position, for
example, to confer shape to the host's breast tissue or an
anatomical shape of the breast. In one preferred embodiment, the
implant is delivered by employing an IMF incision used as the entry
point for dissection, along with a periareolar incision, in a
mastopexy procedure. Once skin removal and dissection is complete,
a three-dimensional shape memory implant can be deployed in vivo
and allowed to resume its preformed three-dimensional shape. The
relative rigidity of the self-reinforcing three-dimensional implant
allows the implant to remain in place. One skilled in the art will
appreciate that these three-dimensional implants can also be
delivered by other minimally invasive methods as well as using more
traditional open surgery techniques.
[0137] The present invention will be further understood by
reference to the following non-limiting examples.
Example 1: Regeneration of Tissue from a Bicomponent P4HB
Implant
[0138] Materials and Methods
[0139] A bicomponent P4HB absorbable implant was prepared from a
thin 60 .mu.m thick extruded film of P4HB and a knitted P4HB
monofilament construct with average pore diameter of approx. 500
.mu.m and an areal density of approx. 182 g/m.sup.2. The film was
bonded to the mesh by ultrasonically welding the layers together
using small pieces of P4HB extrudate (approx. OD 1.5 mm, length
1.27 mm) as a binder. The welding was performed using a model
2000.times. Branson ultrasonic welder with a 5.times.5 inch horn
and a flat metal anvil. The knitted construct was placed on the
anvil and pieces of the extrudate were placed on the knitted
material at a spacing of about 13 to 19 mm. The film was then
positioned so that the pieces of extrudate were between the film
and knitted materials. The horn was lowered and the layers were
welded together with a burst of ultrasonic energy (weld energy 100
J, 0.5 s, amplitude 90% fixed, 0.21 MPa pressure). The molecular
weights (Mw) of the film and knitted materials relative to
polystyrene were 313 kDa and 305 kDa, respectively.
[0140] Six samples of the P4HB implant (51.times.51 mm) were
implanted subcutaneously in the backs of New Zealand white rabbits.
A total of 17 rabbits were implanted; three rabbits for 4, 12 and
26 weeks, and four rabbits for 52 and 78 weeks. Following
explanation, one explant from each rabbit was kept for histological
analysis and the remaining explants (n=5 per animal) were used for
mechanical and molecular weight testing. A total of 15 samples were
received and analyzed for the 4, 12, 26 and 78-week time points,
while 20 samples were received and analyzed at 52 weeks. The
mechanical testing data is summarized in Table 1.
[0141] Results
[0142] The bicomponent implant had a thickness of 0.613 mm, and the
knitted structure had an average pore diameter of approx. 500
.mu.m. The burst pressure of the implant was approximately 3.09
MPa.
[0143] As noted in Table 1, a portion of the 52 and 78-week
explants were tested as received and were observed to have higher
than expected burst values (i.e. the average burst value at 52
weeks is higher than the 26 week value, while the value at 78 weeks
is similar to that at 26 weeks). This is the result of the presence
of in-grown, attached tissue adding to the bursting pressure of the
combined tissue/P4HB explant. When the remaining explants at 52
weeks were treated with collagenase (noted as "enzyme" in Table 1)
to remove the ingrown, attached tissue, many samples of the P4HB
implant were found to have degraded significantly and were
unsuitable for mechanical testing (n=9). The average burst pressure
value (0.17 MPa) of these intact samples (n=5) remaining at 52
weeks after enzyme digestion is recorded in Table 1. After 78
weeks, none of the enzymatically digested samples were suitable for
mechanical testing so burst pressure at 78 weeks was only recorded
for as received samples (i.e. without enzyme digestion). It should
be noted that the 4, 12 and 26-week explants were only tested as
received (i.e. without enzyme digestion), and that the P4HB film
became rapidly porous and was quickly degraded.
[0144] The data in Table 1 demonstrate that the P4HB implant is
replaced in vivo by regenerated host tissue with a significant
burst pressure that is more than sufficient to support a
reconstructed breast. At 78 weeks, the average burst pressure of
the as received explants was 0.98 MPa, while the enzymatically
digested explants demonstrated that the original P4HB implant did
not contribute to the burst pressure and was substantially
degraded. At 52 weeks, the P4HB implant was also found to be
significantly degraded with the enzymatically degraded P4HB implant
having a residual burst pressure of just 0.17 MPa. In contrast, the
explants at 52 weeks that had not been enzymatically digested had
an average burst pressure of 1.47 MPa. This means that at 52 weeks,
the majority of the burst pressure is due to the tissue, rather
than the P4HB implant, and at 78 weeks all the burst pressure is
due to the regenerated tissue.
TABLE-US-00001 TABLE 1 Properties of Implant over Time after
Digestion Implant Time # Tested Burst Pressure % Strength (wks) (n)
MPa Retention 0 4 3.08 100 4 15 2.37 77 12 15 1.39 45 26 15 1.11 36
52 5 0.17 5 enzyme digested 52 6 1.47 48 as received 78 6 0 ND
enzyme digested 78 9 0.98 32 as received
Example 2: Regeneration of Tissue from a P4HB Implant of Thermally
Bonded Fibers
[0145] Materials and Methods
[0146] A P4HB implant was prepared from thermally bonded fibers of
P4HB with a thickness of approximately 1 mm, an areal density of
260 g/m.sup.2, and a weight average molecular weight relative to
polystyrene of 129 kDa. The burst pressure of the P4HB implant was
0.91 MPa, and the pore size of the implant was approximately 50
.mu.m.
[0147] Results
[0148] The P4HB implants were implanted subcutaneously in the backs
of New Zealand white rabbits for 2, 4, 8, 12 and 24 weeks. The
ability of the P4HB implants to regenerate host tissue with
significant burst pressure was determined. The mechanical testing
and molecular weight data for the explants are summarized in Table
2. In contrast to Example 1, none of the explanted samples were
enzymatically digested with collagenase for mechanical testing
because the thermally bonded fibers of the P4HB implant were found
to degrade very rapidly. As shown in Table 2, no recoverable P4HB
polymer could be found at the 26-week time point, and therefore the
molecular weight of the polymer could not be determined at this
time point. All the values shown in Table 2 are for the burst
pressure of the as received explants, and are therefore composite
values of the residual P4HB implant and the ingrown tissue.
[0149] As shown in Table 2, the burst pressure of the explanted
samples initially decreased during the first 8 weeks, but then
began to increase until the burst pressure reached approx. 0.96 MPa
at 26 weeks. This data shows that the P4HB implant can be replaced
by regenerated host tissue in vivo, and that the new tissue would
be able to support a significant load in a reconstructed
breast.
TABLE-US-00002 TABLE 2 Properties of Implant over Time Time Mw
Burst Pressure % Strength (wk) (kDa) MPa Retention 0 129 0.91 100 2
123 0.69 76 4 111 0.65 72 8 95 0.43 47 12 83 0.46 50 26 NA 0.96
105
Example 3: Preparation of an Asymmetric Shaped P4HB Implant
[0150] A teardrop shaped P4HB implant having the dimensions and
shape shown in FIG. 1 was prepared from a knitted P4HB monofilament
structure with a pore diameter of approximately 500 .mu.m,
thickness of 0.5 mm, areal density of approx. 182 g/m.sup.2, suture
pullout strength of 5.6 kgf, and a burst pressure of 3.06 MPa. The
implant was cut to the desired shape with scissors.
Example 4: Minimally Invasive Delivery of a Two-Dimensional P4HB
Implant Minimizing Buckling and Bunching of the Implant Upon
Placement
[0151] A minimally invasive dissection was performed on a cadaver
wherein two small (2 inch) incisions were created in standard entry
points: a periareolar incision and an inframammary fold incision.
This was followed by blunt dissection separating the breast
parenchyma from the skin to create a tissue plane from the medial
to the lateral sides of the lower pole of the breast. A
two-dimensional shaped implant was rolled into a small diameter
cylinder, and placed inside an insertion device suitable for
deployment of the implant in vivo. The implant was deployed from
the insertion device, and placed to confer shape to a breast with
minimal buckling and bunching of the implant.
Example 5: Preparation of a P4HB Implant Comprising a
Three-Dimensional Scaffold Designed to Confer Shape to a Breast, or
Anatomical Shape of a Breast, Wherein the Three-Dimensional Shape
can be Temporarily Deformed to Allow for Implantation, and Resume
its Three-Dimensional Shape after Implantation
[0152] A split metal mold consisting of an inwardly curving half
and a mating outwardly curving half was prepared, with a
semicircular groove placed in the outlying border of the inwardly
curving half, as shown in FIG. 3. A P4HB monofilament extrudate was
cut to length, and pushed into the semicircular groove with part of
the monofilament protruding from the groove. A knitted P4HB
monofilament mesh, measuring approx. 15.times.20 cm, with a pore
diameter of approximately 500 .mu.m, thickness of 0.5 mm, areal
density of approx. 182 g/m.sup.2, suture pullout strength of 5.6
kgf, and a burst pressure of 3.06 MPa, was draped over the entire
surface of the inwardly curving half of the metal form and the
monofilament in the semicircular groove. The mating outwardly
curving metal form was gently placed over the mesh, and the two
halves of the split metal mold were clamped together to form a
block. The block was uniformly heated on all sides by placing the
block in hot water maintained at 56.degree. C. for 5 minutes. The
block was then uniformly cooled for 1 to 2 minutes by placing the
block into a water bath at ambient temperature. The block was
disassembled, and the mesh shape gently lifted from the metal mold.
Unwanted compressed extrudate was removed from the implant by
trimming the outlying border.
Comparative Example 5: Preparation of a P4HB Implant from a
Scaffold with a Three-Dimensional Shape without a Reinforced
Outlying Border
[0153] A split metal mold consisting of an inwardly curving half
and a mating outwardly curving half was prepared, but without a
semicircular groove placed in the outlying border of the inwardly
curving half (as described in Example 4). A knitted P4HB
monofilament mesh, measuring approx. 15.times.20 cm, with a pore
diameter of approximately 500 .mu.m, thickness of 0.5 mm, areal
density of approx. 182 g/m.sup.2, suture pullout strength of 5.6
kgf, and a burst pressure of 3.06 MPa, was draped over the entire
surface of the inwardly curving half of the metal form. The mating
outwardly curving metal form was gently placed over the mesh, and
the two halves of the split metal mold were clamped together to
form a block. The block was uniformly heated on all sides by
placing the block in hot water maintained at 56.degree. C. for 5
minutes. The block was then uniformly cooled for 1 to 2 minutes by
placing the block into a water bath at ambient temperature. The
block was disassembled, and the three-dimensional mesh gently
lifted from the metal mold. Unwanted mesh was removed from the
implant by trimming.
Example 6: Minimally Invasive Delivery of a Three-Dimensional P4HB
Implant with a Reinforced Outlying Border
[0154] The implant prepared in Example 5 (and with a reinforced
outlying border) was rolled into a small diameter cylinder, and
placed inside an insertion device suitable for deployment of the
implant in vivo. The implant assumed its original three-dimensional
shape when the implant was deployed from the insertion device.
Comparative Example 6: Attempted Minimally Invasive Delivery of a
Three-Dimensional P4HB Implant without a Reinforced Outlying
Border
[0155] The implant without a reinforced outlying border prepared in
Comparative Example 5 was rolled into a small diameter cylinder,
and placed inside an insertion device suitable for deployment of
the implant in vivo. The implant failed to assume its
three-dimensional shape unaided when the implant was deployed from
the insertion device. This example demonstrates the need to
self-reinforce the outlying border of a P4HB implant in order for
the implant to have shape memory and be able to confer shape to a
breast.
[0156] Modifications and variations of the methods and compositions
will be apparent from the foregoing detailed description and are
intended to come within the scope of the appended claims.
* * * * *